Pathological Condition
Definition
Female infertility refers to women's inability to reproduce through the
natural and normal methods. Infertility is not the natural status of a healthy
adult creature as in humans, it is a case among women who are unable to be
pregnant or unable to carry pregnancy to full term.
It can also be referred to as a disease that affects the reproductive
system of women as it makes it fail in achieving the clinical pregnancy after
the regular sexual intercourse which is unprotected.
It is also the inability of a sexuality active couple to achieve
pregnancy in the time period of one year as this can be referred to the male'
infertility by different clinical interventions or from laboratory evaluations
for the semen. (Dag and Dilbaz, 2015)
Epidemiological definition of infertility
It is a case of non-pregnancy for women who are at the reproductive age
between 15 and 49 and who are at the risk of being pregnant as they don't use
any contraception and report not successful pregnancy for two years period or
more. (Dag and Dilbaz, 2015)
Primary and Secondary Infertility
Infertility can be either primary or secondary as the primary
infertility is when the woman is unable to give birth to a child or even be
pregnant while the secondary infertility refers to the woman who is unable to
give a second birth to a child and she had one before this inability but
currently she is not able to be pregnant.
(WHO, 2017).
Incidence
In a research there was a prevalence of infertility estimated with 12.5%
(CI 95% 11.7–13.3) among women and 10.1% (CI 95% 9.2–11.1) among men. Increased
prevalence was related to later cohabitation with a partner and higher
socio-economic status. The reported prevalence of asking for help was 57.3% (CI
95% 53.6–61.0) among women.
There are relationship factors that can be associated with infertility
experience as according to the research, infertility may be highest with women
who are older age and those who first got married at age 35 or more. It can
also be more prevalent among women who were treated from depression for more
than 12 months. (Datta et al, 2016)
Symptoms
There are many symptoms that should be clear for infertility such as the
woemn's inability for being pregnant and having long menstrual cycle that comes
every more than 35 days or having a very short one that comes every 21 days or
less. This means that the menstrual cycle is irregular and if it is absent too,
this means symptoms of infertility as ovulating here is stopped or having
problems. There may also be no signs or symptoms of infertility clear on the
patient. (Fodina et al, 2016)
When the patient have to see a doctor
When seeking for help may be based on the patient's age as:
·
Up to age 35, most
doctors ask them and advise them to try to be pregnant for at least a year
before making testing or receiving treatment.
·
If the patient is
between 35 and 40, discuss the patient's concerns and signs with the doctor
after six months trials.
·
If the patient is older
than 40, the patient's doctor may want
to start testing or treatment currently and on time.
If the woman and her husband are well aware of some infertility problems
and ask doctor's advice, the doctor will start testing and treatment. This also
occurs when the patient suffers a history of irregular or absent menstrual
cycle or other relevant diseases and health problems. (Sharma et al, 2015)
Risk Factors
There is a number of risk factors that are associated with infertility
in women such as the following ones:
Age
The older women are, the less fertility they have. At the age of
mid-thirties, fertility begins to decline at women and this is due to the less
eggs amount produced by their ovaries. Another problem is that with age, the
eggs' quality decrease and there is a risk of having chromosomal abnormalities
in the eggs. There are also risks of birth defects as well as miscarriage in
addition to the probability of having different health problems that may affect
fertility of women.
Weight
The women's fat cells produce usually about 30% of the women estrogen
that is supposed to be mainly produced in the woman's ovaries and this means
that the male hormones that are produced by the women's bodies by the adrenal
glands are turned into estrogen. This means that very high weight levels can
lead to infertility as a result of the abnormal balance of hormones. Women who
are also underweight can have infertility levels because of having low body fat
levels while being overweight can lead to infertility due to the above normal
fat level and this also include women who are suffering eating disorders such
as bulimia nervosa or anorexia and women who suffer very low calories levels
due to very strict diets and having irregular periods resulting from such
diets. Strict vegetarian women also may have problems with fertility if they
lack the needed nutrients and vitamins.
Smoking
Smoking can be very harmful on the ovaries of women as they can lead to
eggs decrease as many studies confirm that there is bigger possibility for
infertility among smoking women rather than non-smokers as the smoke is more
liable to reach the menopause earlier than in the non-smoker women.
Alcohol and Caffeine Usage
Infertility is seen to be highly associated with the excessive usage of
alcohol and caffeine.
Environmental Factors
There are many environmental hazards that may passively affect the
levels of fertility in women such as the industrial solvents, pesticides and
herbicides. These substances include chemicals that can be attracted to the
estrogen of women and affect their
fertility as well as in men too. These chemical can affect the hormones
passively and disrupt them which leads to infertility.
Stress and Fertility
There are different chemical messengers in the women's brains that are
called Neurotransmitters and they work in the hypothalamus gland that has great
control on the stress and reproductive hormones and this in turn passively
affects fertility and hinder infertility treatment. (Shamila and Sasikala,
2011)
Diagnosis
When women are unable to be pregnant in a period of time that exceeds a
year of unprotected sex, they have to consult a doctor who is specialist in
fertility as the doctor can make the required fertility tests that are very
necessary especially when the women are at the age of 35 and more or if the
woman has some risk factors related with the case such as weight problems or
smoking for example. The doctor may also make analysis for the men's semen
before making the needed tests for the woman. (Patel et al, 2016)
Medical History and Physical Examination
Completing the medical history is a very important step in the
infertility work up added to the physical examinations. This includes asking
the patient about her history of sexual activities such as its timing,
frequency and menstrual history as well as other life activities such as
smoking, alcohol usage and consumption of caffeine. The doctor also asks about
other medication that is taken by the patient and her emotional health in order
to be helpful guides before testing.
Easy Preliminary Steps
Before making any work up related to fertility, there should be some
steps to be taken in order to reduce cost and help, they include the following:
• Monitor basal body temperature. This step
is very important to decide about the occurrence of ovulation.
• Test the consistency of women cervical
mucus.
• urine test for detecting the luteinizing
hormone (LH) surges.
Laboratory Tests
There are many laboratory tests that can be made for testing the
infertility causes and then to monitor and decide its treatment such as the
blood and urine tests for testing levels of hormones and evaluating them. They
may include hormonal tests for the reserve of ovarian especially to be made in
older women.
Clomiphene Challenge Test
Here the standard fertility drug can be used for testing the ovarian
reserve as here the doctor takes measurements for the FSH in the third day of
the cycle. This is done by giving the woman oral clomiphene on the fifth day
and ninth of the cycle, then the FSH of the women is measured by the doctor on
the tenth day. If the FSH levels are high on third or tenth days, this means
there is low chance for good results.
Tissue Samples
Tests for Autoimmune Disease.
Examples of possible results can include:
• High follicle-stimulating hormone (FSH),
luteinizing hormone (LH) levels and low estrogen levels suggest premature
ovarian failure.
• High LH and low FSH may say that there is polycystic
ovary syndrome or defect in the luteal phase.
• High FSH and high estrogen levels on the
day three of the cycle predict means there are poor success rates in older
women who are trying fertility treatments.
• LH surges indicate that there is ovulation.
• Prolactin levels and thyroid function
should be measured as such hormones can affect fertility in an indirect way.
Special Considerations for Patients with Cancer
Women who suffer cancer and are under treatment of it and in need for
being pregnant have to seek the consultant of a reproductive specialist who can
make a discussion with them about their options. There can be a fertility
preservation method for providing them with the best chances for success in the
fertility such as the embryo cryopreservation as this method depends on
harvesting the eggs of women and then making the needed vitro fertilization and
after that to freeze the embryos for being used later. (Waimey et al, 2015)
Causes
There could be many causes for infertility
and the following medical conditions can be among them as they are able to
damage the fallopian tubes and makes problems with women ovulation as well as
causing some hormonal complications for them.
• Pelvic
inflammatory disease
• Premature ovarian
failure
• Uterine fibroids
• Endometriosis
• Polycystic ovary
syndrome
There are many causes for infertility in women that are related to
medical conditions such as the following ones:
• Ovulation problems
• Blocked fallopian tubes
• Structural problems in
the reproductive system
• Problems with quality
of cervical mucus or eggs
Ovulation
Problems
Ovulation is the process of releasing the egg and it happens in the time
of the menstrual cycle that occurs every month. The most known causes of
infertility are the hormones that are involved into ovulation such as the
Polycystic Ovarian Syndrome (PCOS) as women who have PCOS are not able to
regular ovulation and they suffer menstrual cycles that are absent or frequent.
In PCOS, there are excessive amounts of androgens (male hormones) that
are produced by the ovaries, especially the testosterone. Then comes high
levels of luteinizing hormone (LH) as a consequence for the high androgen
production and also there is low levels of the FSH or the follicle-stimulating
hormone. This process prevents the follicles from the production of the mature
eggs and this shortage results in swelling fluid by the follicles and forming
the cysts. (Agrawal et al, 2014)
https://www.merckmanuals.com/professional/gynecology-and-obstetrics/menstrual-abnormalities/polycystic-ovary-syndrome-pcos
figure 1
Blocked Fallopian Tubes
Sperm can be prevented from fertilization of the egg as it can't reach
it when it is blocked in the fallopian tubes and can't travel to the uterus in
order to apply the implantation process. There are many conditions when it is
blocked there such as the Pelvic Inflammatory Disease which is an infection in
the pelvic and the fallopian tubes, Endometriosis. Endometriosis which is a
condition where cells which are in line in the uterus growing in other areas
outside of the uterus, examples are the ovaries. Uterine or Abnormal Scarring
and Uterine Fibroids as they may contain some substances that block the way in
the fallopian tubes and sperm can't go reach the eggs.
Other Causes of Female Infertility
There are other possible causes for women infertility such as the
following ones:
• Elevated
Prolactin Levels:
Prolactin is a type of hormone that is produced into the pituitary gland
which is stimulating the development of breast and milk production during the
time of with pregnancy. When there are higher levels of that hormone which is
referred to as (hyperprolactinemia), ovulation is inhibited.
• Congenital
Structural Abnormalities:
Infertility may be caused by Congenital reproductive tract abnormalities
as such malformations normally leave its effect on the vagina or the uterus.
Women who are born by women who had taken diethylstilbestrol (DES) while they
are pregnant are at higher risk of getting problems in uterine or fallopian
tube that have relation to infertility. Yet still some women that are already born
and having uterine can be pregnant successfully. Some of such problems can be
corrected via surgery.
• Cervical Mucus:
Infertility can also be affected
by either low amounts of cervical mucus or bad quality related to cervical
mucus. Problems related to cervical mucus can have relation to prior surgeries,
certain medication and hormonal imbalances.
• Egg
Quality:
The number of women's egg decrease as long as they grow older and this
doesn't mean that young women don't have problems with eggs but they may have
them too, this can normally be caused by some medical conditions or having
impaired ovaries due to some treatments. These treatment may be cancer
treatment such as chemotherapy or radiation as they can leave passive effect
over the egg development or even damage them. (Masoumi et al, 2015)
Management of the
Disease
Treatment
For treating infertility, there are many procedures that should be done
at first. It should investigate any other medical condition that may be
relevant to the problems of infertility. If this procedures don not stop the
infertility problem, there should be
other extra steps such as the following ones:
- measures of
lifestyles: (examples having a healthy weight, stopping
smoking, organizing time of the sexual activity considering the
ovulation cycle)
- Drugs to induce
ovulation, examples the clomiphene and gonadotrophins usage.
- Assisted
reproductive technologies (ART), examples the vitro fertilization (IVF)
(Ezzell, 2016)
